While studying to be a therapeutic recreation specialist in college, I worked as a lifeguard and swim instructor at a small, warm-water local pool, where many seniors came to swim and socialize. It was during that time that I first became interested in the idea of using aquatics as a therapeutic modality.

During the senior swim time, I regularly observed an elderly gentleman hobbling in slowly with his cane at his side. His posture was bent and his slow, difficult movements told of his pain with each arthritic step. Once he made his descent into the warm water, his posture relaxed and his movements became visibly smoother and less painful. He spent the next half hour leisurely stretching, paddling about, and socializing with the other pool patrons. When the old man exited the pool, he looked like a younger, more limber version of himself. However, the most marked improvement in his appearance was his attitude. The man always smiled and bid me a fond farewell after each session in the pool. This experience piqued my interest in the use of aquatics as a tool for rehabilitation, as well as a viable exercise option for people with disabilities who are unable to exercise safely on land.

People with disabilities are often caught in a cycle of pain, depression, and stress. Disability can lead to social isolation, an external locus of control (believing that one does not have choice or possess control of one’s destiny), and the belief that exercise and fitness is impossible for them. Aquatic therapy is able to break this chronic pain cycle largely because of the unique properties of water.

How Does it Work?

Individuals with traumatic brain injury (TBI) or other special populations may be unable to exercise on land, but often can do so comfortably in the water. The buoyancy of water causes the individual to feel an upward thrust when submerged. This force acts in the opposite direction of gravity. Buoyancy allows for a variety of exercises to be performed in the pool with minimal equipment. In addition, people with balance deficits may experience less fear of falling while walking and exercising in the pool.

Exercises performed in water can be adapted to resist the upward thrust of buoyancy, support the upward thrust of buoyancy, or to assist this upward thrust. Submersion decreases weight bearing by up to 90% when submerged in neck deep water, so an individual who is unable to support their body weight on land is often able to walk with minimal support in the pool. Other benefits of buoyancy are that the water supports weak muscles, enhances flexibility and range of motion, and increases the ease of handling for the therapist.

Hydrostatic pressure is a wonderful benefit of aquatic therapy. Hydrostatic pressure is the force exerted on the immersed body by fluid molecules. No movement is necessary by the individual in order to reap the many benefits of hydrostatic pressure. I use this phenomenon as a motivational tool for my clients. I might say, “Let’s just get in the water today and let the water do its work.” This is often enough to get someone motivated enough to try the pool.

Hydrostatic pressure decreases pain and edema, which in turn increases range of motion. It also increases venous return and circulation by assisting the heart and decreasing blood pooling in extremities. Hydrostatic pressure turns down the body’s reticular (activating) system (the brain’s system of arousal), dampening tactile sensory input to the brain. This is partly why the water is such a calming environment for most people. Individuals who are tactilely defensive (having a negative response to touch) are often able to tune out their surroundings and focus on and enjoy being in the pool.

The benefit of being submerged in the water is that the individual experiences equal pressure everywhere. Healthy individuals will probably not even notice this slight “squeezing in” feeling, which is similar to the effects of wearing compression stockings. However, an unhealthy person may notice the squeezing sensation, and it may cause some anxiety. In such cases, gentle encouragement and conversation to redirect attention may be helpful. Submersion also places increased demands on the respiratory system, allowing for increased exhalation. Therefore, the respiratory muscles are forced to work a bit harder in the water, which causes these muscles to become more toned even without movement in the water.

Practitioners should also be aware of the complications that water can pose in therapy or exercise. Buoyancy might cause stability problems both for the practitioner and for the individual. However, this buoyancy can provide individuals with an excellent core stability workout (building the trunk musculature to control the position of the lumbar spine). In addition, buoyancy can make it difficult for individuals to get balanced in the water because flaccid, weak extremities may float and spastic, flexed extremities may sink. An individual in the supine position will tend to roll toward the spastic or “heavy” side. Flotation supports, such as: “water noodles,” lifejackets, or specially designed aquatic floatation devices can help compensate for stability problems. The practitioner should also be careful to watch that the individual remains in a neutral spine position when submerged.

Another consideration that the practitioner should keep in mind is that the experience of wearing a bathing suit in a public place, especially for those with physical disabilities, can be a very sensitive issue. Changing before and after the pool session usually requires extra time as well. Compassion, patience, and a sense of humor can go a long way in a potentially uncomfortable or embarrassing situation.

The therapist should also keep in mind that most people with special needs should enter and exit the water very slowly. This will help the individual adjust to the temperature and pressure of the water, as well as ease anxiety for those who are apprehensive. Individuals with visual impairments should be completely oriented to the pool at the beginning of each session. Assist them in walking around the pool perimeter with a hand on the pool’s edge. Point out landmarks, such as a lifeguard chair and pool ladder. Remember that each day a person may have varying degrees of comfort in the pool.

The water also provides excellent resistance for toning exercises. The higher viscosity of water makes muscles work harder when compared to the same exercises on land. Viscosity can be described as the way the water molecules stick together when you try to move through them. It is harder to move through the water than it is to move on land because the water molecules are sticking to each other and to you. Conversely, it would be harder to move through a pool that is filled with peanut butter than a pool that is filled with water! This viscosity means that more muscle fibers are recruited for each movement through water. The heart must also work harder providing blood to the muscles, which results in cardiovascular fitness, as well as overall toning.

The resistance created by water workouts also creates muscle balance. Many orthopedic issues and most back pain problems can be relieved through developing both sides of the muscle. Since muscle fibers must be equally recruited during flexion and extension when moving through water, aquatic exercise provides the ideal environment for this type of workout.

Resistance can be used to create wonderful progressions for individuals at different levels of fitness. Decreasing the speed of movement decreases the resistance. Inversely, increasing the speed of movements will make the exercise more difficult. While many pools have water resistance equipment available, I have found that many of my clients that use wheelchairs on land prefer to exercise with as little resistance equipment as possible. The joy of aquatic therapy for these individuals is in their ability to experience freedom from equipment in the pool.

The natural resistance in the aquatic environment may be beneficial for individuals with neurological impairments because the water will dampen involuntary spastic movements and tremors. A warmer water pool (around 93 degrees) will be most helpful to dampen involuntary movement. Ideally, the air temperature should be 2 to 3 degrees warmer than the therapy pool. This will keep the participant from feeling chilled when they exit the pool. Thermal clothing can also be used to help the person feel warm. A comfortable humidity level for a therapy pool is around 50 percent.

The water is an ideal environment for muscle reeducation for individuals with neurological impairments. The resistance of the water provides people with cognitive deficits extra time to respond because the body will naturally move slower in the water. When people with TBI have extra time to process their body’s movements, the body is more aware of how it is moving; therefore, aquatic exercise is wonderful for muscle reeducation.

Aquatic Therapy: Then and Now

The professional field of aquatic therapy is still in its infancy, but the use of water for therapeutic purposes is an ancient practice. The ancient Greeks and Romans bathed in hot springs thousands of years ago, enjoying the benefits of improved circulation and relaxation from immersion in the warm water. Swiss monks have long understood the curative properties of water. It is documented that they would lower sick or disabled patients from baskets down cliffs into thermal waters below as early as 1238 AD. This immersion in warm water was known to improve flexibility and decrease pain for the patients.

In the 19th and 20th centuries, a therapeutic spa and medical center was developed in Switzerland, where people would come from many miles to experience the healing power of this special water. In 1957, a flotation support was developed and used in conjunction with exercises performed in this special spa. This method evolved into what is now known as the popular Bad Ragaz Ring Method of aquatic therapy. Using the Bad Ragaz Ring Method, the therapist creates progressions using passive and active exercises, moving the patient through the water in a supine position. This method uses the physical properties of water as a tool for muscle reeducation and uses specific patterns of resistance, relaxation, range of motion, and elongation to build endurance and reduce tone.

Many aquatic exercise methods that are currently en vogue, such as Ai Chi, Ai Chi Ne, aquatic yoga and Pilates also have ancient roots. These methods share the common objectives of focus, breathing, core stability and strength to improve posture, strength and flexibility.

Yoga originated in India and has been practiced for centuries. The word “yoga” in Sanskrit means “a union of the physical self with the spirit.” The practice of yoga both in the water and on land is a practical aid, and should not be confused with a religion or belief system. A multitude of styles of yoga have developed over time, but Hatha yoga is the most popular method practiced in the west. Hatha yoga focuses mainly on static asanas, or poses. Yoga involves a mind-body focus that
is gradual and can be tailored to the individual’s needs and abilities to provide a gentle form of exercise. Yoga can be easily adapted to the water for those with special needs or people looking for a different or more challenging exercise experience.

Joseph Pilates developed the Pilates Method during the World War I era. The Pilates Method is similar to yoga, but focuses on fluid movement through a series of poses. His goal was to develop a series of corrective exercises that tone muscles and improve posture, flexibility and balance. Like yoga, Pilates movements are non-impact and require concentration and mental discipline to be performed correctly. Pilates was originally developed on a special apparatus, but is more commonly practiced today on a mat on the floor. For those who are looking for a new and challenging exercise experience, or those who are unable to safely exercise on land in most environments, adapted aquatic yoga or Pilates may be the answer.

All of these methods can be utilized to develop an excellent clinical program. Yoga and Pilates movements adapted to the water have been proven to limber the joints, increase range of motion, improve circulation, and improve cardiovascular fitness. In addition, the practice of aquatic yoga and Pilates can increase core body strength, increase endurance, stabilize joints, and enable fluid motion and provide “design sense”, the sense that the body is able to move in a way that it was designed to move. Furthermore, this type of water exercise improves posture and balance through the practice of poses and slow, controlled movement. Most yoga and Pilates movement patterns can be performed in waist to neck deep water. The properties of water discussed earlier in this article enhance the experience and allow people of diverse abilities to participate and reap the multitude of benefits.

An Added Benefit

The physical benefits of aquatic therapy are astounding; however, my favorite aspect of aquatic therapy is the psychosocial benefits. Aquatic therapy can reduce stress and anxiety, increase one’s ability to concentrate, enhance a feeling of well-being and confidence, and allow a person in pain to find their center of calm. The pool atmosphere often seems less clinical than a P.T. gym, and most people equate the swimming pool with fun!

I love to see a well-worn wheelchair sitting empty by the side of the pool, while the wheelchair user walks in the pool with perhaps only minimal support from an aide or therapist. While observing a pool therapy session at our facility one day, I noticed something unique. It was difficult to tell which person was the client (who was actually quite impaired) and which person was the therapist, as the two walked and joked side-by-side in the water. The pool atmosphere is very normalizing, especially if therapy sessions can be transitioned to a community pool. At the pool, it is easy for exercise and therapy to naturally evolve into games, recreation, and friendship.

Sandy Oeverman, CTRS, graduated from Calvin College with a degree in Therapeutic Recreation. She has provided services for community Parks and Recreation Departments and the National Multiple Sclerosis Society, as well as the Wildwood and Sojourner’s programs of hope Network Rehabilitation Services in Grand Rapids, Michigan. Sandy is currently studying for the International Council for Aquatic Therapy and Rehabilitation Industry Certification (ICATRIC) and lives in Grand Rapids with her husband and daughter.

Comments (13)

I'm a personal trainer, yoga, pilates, water aerobics and land aerobic instructor for 20 plus years now. I loved this article. I'm going to share it with my staff and use this for education. I love the great comprehension this article took. Such understanding of a little known field of work.

As a patient I can attest to the enormous benefits aquatic therapy provides. I suffer from spasticity in my legs, severe chronic pain both central and peripheral, neurologic and nocieptive, fatigue, tremors and balance problems all due to advanced cervical myelopathy. For over a year in traditional land based PT I worked hard to make little progress. High pain levels kept me from being able to do much of anything until I discovered aqautic therapy in a 92 degree salt water pool. Through twice weekly hour long sessions over the past 2 plus years I have made substantial functional gains while decreasing fatigue. Pain continues to be a daily struggle but my pool program gives me purpose and is wonderful for my morale. Stamina has been greatly increased and I get a short term decrease in spasticity after each visit. The use of ankle floats while performing various exercises allows for significantly better stretches of quads and hammies, while challenging balance, adding resistance, and aiding with foot and ankle propriocetion, i.e giving me a better sense of where my feet and legs are in space. I would encourage therapists to highly recommend to others with compressive spinal cord injuries.

As a fellow CTRS it's nice to see such a well written article out there! I'd love to touch base with you. Please contact me whenever you get a chance at: www.leadchangestherapy.com Looking forward to it! Natalie

Thanks for sharing. I'm a PTA specializing in aquatics for ABI ( acquired brain injury). It is great to see the patients enjoy this therapy so much and look forward to it knowing it helps them so much.

Great article Sandy, my fellow CTRS. It covers not only the effectiveness of Aquatic Therapy for individuals with Traumatic Brain Injury, but also on the effectiveness of this therapy for ALL people with illnesses and disabilities.

For therapists wanting to learn more skills regarding Aquatic Therapy and this population of patients, there is an Ortho / Neuro class being held in the Houston, Texas area in October 2014. Credits are being offered. See link for more info. http://tinyurl.com/kmc6jy2

Thank you for your very informative and well written article. I am 52 and have recently been diagnosed with Ankylising Spondalytis (a form of arthritis) and have been spending hours in our pool. When first waking, at times the pain is difficult to cope with and I head straight for the pool. It brings some relief from the pain almost instantly but more importantly has given me a sense of control over what can feel overwhelming.. My ability to move and exercise in the water is such a blessing and I find if I do not swim, the pain the next day will be worse. All the benefits you mention in your article are there. I wish every person who is in need of water therapy could have access to it. Is there an organization that links private pool owners with those who do not have access? Thank you again for your insightful and well considered comments.

I am 59, female and have had occasional clotting problems in my left leg since pregnancy with my daughter, 32 years ago. I take 20 mg of coumadine daily and seizure medication. I discovered recently after a neck/stomach/leg scan that the arteries in my legs are narrowed. Right leg, with slight numbness in the toes, is listed as mild and left leg, more toe numbness where my blood clots have occurred is listed as moderate. I am an active person. The diagnosis from the scan explains the tired legs as I attempted to walk and exercise more in earlier years, trying to reach certain weight loss goals. I was prescribed to aquatic therapy by my doctor after the scanning earlier this summer. It is unbelievable how much better I feel, not to mention 11 lbs. lost at my neurological exam today! I would like to encourage anyone, especially women, to consider aquatic therapy as an exercise alternative - for circulatory improvement, muscle build up and as the writer stated, a place to go for a while and improve your health by just having fun. The exercises are nearly effortless because of the constant support of the water on every side as you move. My stairs to my bedroom were becoming such a chore for me and I dreaded making the climb at night. I am beginning to get up the stairs easier. Instead of bending over, using the same foot for the step up all of the time, I now walk up like a step of stairs is supposed to be taken - left, right, left, right, etc. My climb will become faster and easier as my exercises continue. I am so thankful for aquatic therapy and the strength it really doesn't take, giving me back the strength I really need. Thank you for your article. It makes so much sense and explains that I am accomplishing more than I ever imagined. Again, thanks. Dovie

This program is made possible in part by a grant from the Bob Woodruff Foundation, which is dedicated to ensuring that impacted post-9/11 veterans, service members, and their families are thriving long after they return home.